Recurring concern
Unreliable emergency access to hospital care
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Request correctionFirst reported 25 Feb 2014•Latest report 5 Jun 2026
What this concern includes
Includes failures of controls dedicated to emergency hospital access, including recognition of need, escalation, approval for release or transfer, ambulance activation and coordination where these affect timely access to hospital care.
Not included
- Excludes generic training, staffing, communication or protocol deficiencies not explicitly tied to emergency access to hospital care.
- Excludes routine or non-emergency referrals and transfers.
- Excludes unrelated emergency procedures or transport arrangements that do not concern access to hospital care.
- Reports
- 50
- Individual concerns
- 60
- Date range
- 2014–2026
- Stated actions
- 99
Distinct published reports
A report can raise multiple concerns
First to latest report issue date
Described in published responses
Reports over time
Reports over time
Reports about this concern issued each year.
* 2026 is projected from reports observed to 7 Sep 2026.
Most frequent recipients
Most frequent recipients
Reports about this concern sent to each recipient.
Concerns and responses across reports
Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.
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Concerns raised1
Failure to discuss alternative hospital conveyance options with the person arranging care
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
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Action
Implement the agreed London-wide protocol requiring clinicians to explain ambulance delays and self-transfer risks, involve callers, provide updates, and reiterate worsening instructions.
Stated by London Central & West Unscheduled Care Collaborative Limited
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
Responsibility for the concern about explaining risks and discussing non-ambulance conveyance rests with the London Central and West Unscheduled Care Collaborative and Dr Ladbrooke.
Stated by London Ambulance Service NHS Trust
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Concerns raised1
Lack of an agreed pathway for detained patients requiring assessment and treatment at A & E
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
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Action
Implement and monitor an agreed acute-care pathway with clinician communication channels and a flowchart for detained mental-health patients requiring planned or emergency acute care.
Stated by James Paget University Hospitals NHS Foundation Trust -
Action
Complete development of a joint referral pathway enabling mental health inpatients to receive timely Emergency Department care through advance notification and agreed arrival times.
Stated by the Queen Elizabeth Hospital, King'S Lynn, NHS Foundation Trust -
Action
Develop local protocols with acute-hospital colleagues for timely, least-distressing assessment of patients with mental health needs and incorporate them into policy.
Stated by Norfolk and Suffolk NHS Foundation Trust
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Concerns raised1
Delays in accepting transfer of suspected aortic dissection patients while awaiting CT imagery
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
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Action
Clarify and reinforce to cardiothoracic registrars that aortic dissection referrals must be discussed immediately with the duty consultant, who decides transfer and any pre-transfer CT review.
Stated by Guy'S and St Thomas' NHS Foundation Trust -
Action
Extend the open-door policy to ascending-aorta and arch dissections, enabling consultant-authorised immediate transfer with guaranteed theatre and critical-care capacity.
Stated by Guy'S and St Thomas' NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
Clarified consultant escalation and guaranteed immediate transfer arrangements are considered sufficient to prevent recurrence of confusion and delay.
Stated by Guy'S and St Thomas' NHS Foundation Trust
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Concerns raised1
Unavailability of an emergency code protocol for calling an ambulance
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
Responsibility for establishing the prison’s emergency medical response code protocol rests with the Prison Service, specifically HMP Dartmoor’s Governor.
Stated by Dorset Healthcare University NHS Foundation Trust
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Concerns raised1
Delays and lack of clarity in control-room responses to medical emergencies
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
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Action
Revise local contingency plans and reissue emergency instructions requiring timely ambulance calls and defining medical emergency response codes.
Stated by Frankland Prison
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Concerns raised3
Failure to immediately admit children when meningitis is a realistic possibility
Failure to immediately refer children with infected umbilical cords to hospital at first OOH attendance
Failure to escalate seriously ill children to hospital during OOH assessment
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
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Action
Implement NICE feverish-illness guidance in the out-of-hours service using PEWS and assessment templates.
Stated by North Cheshire and Mersey NHS Foundation Trust -
Action
Conduct quarterly clinical audits of practitioners’ records and provide supervision and competency action plans where practice falls short.
Stated by North Cheshire and Mersey NHS Foundation Trust -
Action
Provide training on managing severely ill children for out-of-hours GPs alongside mandatory and statutory training.
Stated by North Cheshire and Mersey NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
The clinical data produced a PEWS score of 0–2, which did not indicate that further action or hospital referral was required.
Stated by North Cheshire and Mersey NHS Foundation Trust
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Concerns raised4
Lack of an agreed protocol for seeking approval for emergency release to hospital
Failure of the on-call system to provide reliable telephone access to the responsible approval function
Failure to prioritise preservation of life over security concerns in emergency medical decisions
Failure to appropriately act on clinical judgement of a potentially life-threatening condition
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to request an ambulance promptly after a level one call
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
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Action
Deliver and disseminate an emergency healthcare response publicity campaign to operational, non-operational and healthcare staff.
Stated by Care UK Limited -
Action
Review emergency care arrangements, including staff training and standardisation of emergency bags.
Stated by Care UK Limited
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Concerns raised1
Failure to identify urgent presentations requiring immediate hospital referral
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to arrange an emergency theatre
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
Data last updated 7 September 2026